Tuesday, March 15, 2016

A number of clinical and
epidemiological studies have indicated that children with autism spectrum
disorder (ASD) are at increased risk for gastrointestinal (GI) problems. Research
suggests that certain behaviors among children with ASD may reflect underlying GI
problems and that the presence of these behaviors may indicate the need to
evaluate a child with ASD for GI problems. Specific behavior problems proposed
as possible expressions of GI distress include sleep disturbances, stereotypic
or repetitive behaviors, self-injurious behaviors, aggression, oppositional
behavior, irritability or mood disturbances, and tantrums. A recent pediatric
consensus report called for additional research on the association between problem
behaviors and GI problems, and for the development of a screen for GI problems
in autistic children.

Research

A brief report published
in the Journal of Autism and Developmental Disabilities compared the behavioral
features of children with and without a history of GI problems. The purpose of
this population-based study of 487 children with ASD, including 35 (7.2%) with
a medically documented history of GI problems, was to determine whether particular
behavioral characteristics occur more frequently among those who have been diagnosed
with a GI problem than those without a medically documented history of GI
problems. The researchers implemented a cross-sectional study of children who were
8 years of age and met the case definition for ASD through the Centers for
Disease Control and Prevention’s Autism and Developmental Disabilities
Monitoring (ADDM).

Eight behavioral features
were identified that may be indicative of GI problems among children with ASD which
had analogous measures in the ADDM data set: 1. abnormalities in sleeping; 2. stereotyped
and repetitive motor mannerisms; 3. self-injurious behaviors; 4. abnormal
eating habits, 5. abnormalities in mood or affect; 6. argumentative, oppositional,
defiant, or destructive behaviors; 7. aggression; and 8. temper tantrums. Demographic
data, healthcare and medical records, descriptions of behaviors, diagnostic summaries,
psychometric test results, and information about co-occurring disorders or
disabilities were collected and entered into a centralized composite record and
reviewed by trained clinicians according to a specified protocol to determine
case status and associated behavioral features (e.g., abnormalities in sleeping).

Results

The results indicated that
children with sleep abnormalities were more likely to have a medically
documented history of GI problems (11%) than those without sleep problems (3.6%).
Similar associations were seen for argumentative, oppositional or destructive
behavior, abnormal eating habits, mood disturbances and tantrums, although the
associations for mood disturbances and tantrums did not reach statistical significance.
In contrast, the researchers found no associations between the presence of GI
problems and stereotypic/repetitive behaviors and self-injurious behaviors. Notably, nearly all of the children with ASD,
including all 35 with a documented history of GI problems, exhibited at least
one of the behavior problems hypothesized to be potential indicators of GI
distress. For this reason, these behaviors would not be useful as a potential
screen for GI problems in that virtually all children with ASD would
potentially be referred for GI evaluations.

Implications

This study provides some
support for the association between selected behavioral
characteristics in autistic children and the occurrence of GI problems. The
study found significant positive associations for several behaviors
hypothesized to be expressions of GI problems in children with ASD. Certain
behaviors, including abnormalities in sleep patterns, abnormalities in eating
habits, and argumentative, oppositional, defiant or destructive behavior were
described significantly more often in autistic children who also had GI
problems than in those with ASD and no history of GI problems.

Perhaps the most important
contribution of this study is the finding that the behavioral characteristics
hypothesized to be expressions of GI problems are very common in autistic children, yet not specific to those with GI problems. Although GI problems may
contribute to selected behaviors in some children with ASD, these behaviors are
also frequent in children with and without ASD (nearly all children had
1 or more behaviors) and are unlikely to efficiently predict GI problems in
children with ASD. As a result, the presence of these behaviors would not be
useful on their own for screening or identifying children requiring GI
evaluation.

Practitioners should be aware that certain behavioral problems observed in autistic children may be indicative of a child’s response to, or attempt to
communicate the discomfort of, an underlying GI problem. This condition can
seriously affect the individual’s quality of life and ability to participate education
and therapeutic activities. Consideration of medical, biological, or
physiological co-occurring conditions, genetic susceptibility, diet and
nutrition, and medication use are necessary to determine whether co-occurring behavioral
problems and GI distress may be present in a child with ASD. A comprehensive developmental assessment approach requires the use of multiple
measures including, but not limited to, verbal reports, direct observation,
direct interaction and evaluation, and third-party reports. This should
include a record review, developmental and medical history, further medical
screening and/or evaluation, and parent/caregiver interview. Lastly, further
research is needed to develop recommendations for diagnostic evaluation and
management of GI problems for individuals on the spectrum.

Wednesday, March 2, 2016

Parents worldwide often
experience a range of emotions when their child is first diagnosed with autism,
including shock, sadness and grief, anger, and loneliness. Mothers, in
particular, appear to face unique challenges that potentially have an impact on
their mental health and wellbeing. This includes high levels of psychological
distress, depressive symptoms, and social isolation. Almost 40% of mothers
report levels of clinically significant parenting stress and between 33% and
59% report significant depressive symptoms following a diagnosis of autism
spectrum disorder (ASD). The prevalence of psychological distress among mothers
of children with ASD suggests a need to address parental mental
health during the critical period after the child’s autism diagnosis and when
parents are learning to navigate the complex system of autism services.

Research

A study published in the
journal Pediatrics
examined whether a brief cognitive behavioral intervention, problem-solving
education (PSE), decreases parenting stress and maternal depressive symptoms
during the period immediately following a child’s diagnosis of ASD. A randomized
clinical trial compared 6 sessions of PSE with usual care. Settings included an
autism clinic and 6 community-based early intervention programs. Participants
were mothers of 122 young children who recently received a diagnosis of ASD.
The intervention group received PSE, a manualized cognitive behavioral
intervention delivered in six 30-minute individualized sessions. The usual care
group mothers received the services specified in the child’s Individualized
Family Service Plan or Individualized Educational Plan (IEP) which typically includes
speech and language therapy, occupational therapy, and social skills training.
Neither specifically includes parent-focused mental health services.

The results indicated that
at a 3-month follow-up assessment, PSE mothers were significantly less likely
than those serving as controls to have clinically significant parental stress
(3.8% vs 29.3%). For depressive symptoms, the risk reduction in clinically
significant symptoms did not reach statistical significance; however, the
reduction in mean depressive symptoms was statistically significant. The
findings demonstrate evidence of PSE’s short-term efficacy and potential to
reduce clinically significant psychological distress during this critical
juncture—when parents first learn of an ASD diagnosis and must navigate a
complex service system on their child’s behalf.

Implications

The findings have
implications for practice in both clinical and educational contexts. Practitioners need to be aware that parents
experience a myriad of emotions when receiving a diagnosis of ASD and many go
through stages of grief. Likewise, professionals working with families of
children with an ASD should be aware of negative effects of stress and anxiety and
assist in offering services that directly address parental needs and support
maternal mental health. Strengthening maternal problem-solving skills might
serve as a buffer against the negative impact of life stressors and thereby
reduce parental stress and attenuate depressive symptoms in the months
immediately following a child’s ASD diagnosis. Future research is needed to
examine the effect of intervention over a longer follow-up period and to assess
whether the intervention worked differently among subgroups of mothers, which
could help better identify those who are most likely to benefit from the
intervention.

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